Provider Demographics
NPI:1902927056
Name:ARCHIBALD, BRAD (OTR)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-0354
Mailing Address - Country:US
Mailing Address - Phone:208-351-0651
Mailing Address - Fax:208-528-0989
Practice Address - Street 1:4893 CAMAS CREEK CIR.
Practice Address - Street 2:
Practice Address - City:IONA
Practice Address - State:ID
Practice Address - Zip Code:83427
Practice Address - Country:US
Practice Address - Phone:208-351-0651
Practice Address - Fax:208-528-0989
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTA930OtherBLUE CROSS GROUP #
IDW0996OtherBLUE CROSS PROVIDERNUMBER
ID16-55702Medicare ID - Type UnspecifiedPROVIDER NUMBER